Review Article: is Helicobacter pylori relevant in the management of reflux disease?

Randomized, multicenter study: on-demand versus continuous maintenance treatment with esomeprazole in patients with non-erosive gastroesophageal reflux disease

Background

Most patients with gastroesophageal reflux disease experience symptomatic relapse after stopping acid-suppressive medication. The aim of this study was to compare willingness to continue treatment with esomeprazole on-demand versus continuous maintenance therapy for symptom control in patients with non-erosive reflux disease (NERD) after 6 months.

Methods

This multicenter, open-label, randomized, parallel-group study enrolled adults with NERD who were heartburn-free after 4 weeks’ treatment with esomeprazole 20 mg daily. Patients received esomeprazole 20 mg daily continuously or on-demand for 6 months. The primary variable was discontinuation due to unsatisfactory treatment. On-demand treatment was considered non-inferior if the upper limit of the one-sided 95 % confidence interval (CI) for the difference between treatments was <10 %.

Results

Of 877 patients enrolled, 598 were randomized to maintenance treatment (continuous: n = 297; on-demand: n = 301). Discontinuation due to unsatisfactory treatment was 6.3 % for on-demand and 9.8 % for continuous treatment (difference −3.5 % [90 % CI: −7.1 %, 0.2 %]). In total, 82.1 and 86.2 % of patients taking on-demand and continuous therapy, respectively, were satisfied with the treatment of heartburn and regurgitation symptoms, a secondary variable (P = NS). Mean study drug consumption was 0.41 and 0.91 tablets/day, respectively. Overall, 5 % of the on-demand group developed reflux esophagitis versus none in the continuous group (P < 0.0001). The Gastrointestinal Symptom Rating Scale Reflux dimension was also improved for continuous versus on-demand treatment. Esomeprazole was well tolerated.

Conclusions

In terms of willingness to continue treatment, on-demand treatment with esomeprazole 20 mg was non-inferior to continuous maintenance treatment and reduced medication usage in patients with NERD who had achieved symptom control with initial esomeprazole treatment.

Trial registration

ClinicalTrials.gov identifier (NCT number): NCT02670642; Date of registration: December 2015.

Consequences of Helicobacter pylori infection in children

Although evidence is emerging that the prevalence of Helicobacter pylori (H. pylori) is declining in all age groups, the understanding of its disease spectrum continues to evolve. If untreated, H. pylori infection is lifelong. Although H. pylori typically colonizes the human stomach for many decades without adverse consequences, children infected with H. pylori can manifest gastrointestinal diseases. Controversy persists regarding testing (and treating) for H. pylori infection in children with recurrent abdominal pain, chronic idiopathic thrombocytopenia, and poor growth. There is evidence of the role of H. pylori in childhood iron deficiency anemia, but the results are not conclusive. The possibility of an inverse relationship between H. pylori and gastroesophageal reflux disease, as well as childhood asthma, remains a controversial question. A better understanding of the H. pylori disease spectrum in childhood should lead to clearer recommendations about testing for and treating H. pylori infection in children who are more likely to develop clinical sequelae.

Guidelines for the management of dyspepsia

Dyspepsia is a chronic or recurrent pain or discomfort centered in the upper abdomen; patients with predominant or frequent (more than once a week) heartburn or acid regurgitation, should be considered to have gastroesophageal reflux disease (GERD) until proven otherwise. Dyspeptic patients over 55 yr of age, or those with alarm features should undergo prompt esophagogastroduodenoscopy (EGD). In all other patients, there are two approximately equivalent options: (i) test and treat for Helicobacter pylori (H. pylori) using a validated noninvasive test and a trial of acid suppression if eradication is successful but symptoms do not resolve or (ii) an empiric trial of acid suppression with a proton pump inhibitor (PPI) for 4-8 wk. The test-and-treat option is preferable in populations with a moderate to high prevalence of H. pylori infection (> or =10%); empirical PPI is an initial option in low prevalence situations. If initial acid suppression fails after 2-4 wk, it is reasonable to consider changing drug class or dosing. If the patient fails to respond or relapses rapidly on stopping antisecretory therapy, then the test-and-treat strategy is best applied before consideration of referral for EGD. Prokinetics are not currently recommended as first-line therapy for uninvestigated dyspepsia. EGD is not mandatory in those who remain symptomatic as the yield is low; the decision to endoscope or not must be based on clinical judgement. In patients who do respond to initial therapy, stop treatment after 4-8 wk; if symptoms recur, another course of the same treatment is justified. The management of functional dyspepsia is challenging when initial antisecretory therapy and H. pylori eradication fails. There are very limited data to support the use of low-dose tricyclic antidepressants or psychological treatments in functional dyspepsia.

Indicaciones y consecuencias de la erradicación de Helicobacter pylori en la enfermedad por reflujo gastroesofágico

Several epidemiological data indicate that H. pylori infection prevalence in patients with gastroesophageal reflux disease (GERD) is lower than that reported in respective controls, which would suggest that the organism plays a protective role against this disease. On the other hand, most studies demonstrate that the presence of the infection in patients with GERD does not negatively affect the therapeutic efficacy of proton pump inhibitors (PPIs), and, in case of negatively influencing it, the effects are not clinically relevant and are easily controllable with standard antisecretory treatment. Therefore, the decision to administer H. pylori eradication treatment to a patient should not be influenced by the concomitant presence of GERD. In most cases, H. pylori eradication does not seem to induce GERD development, and it does not seem to worsen GERD when it was already present. Nevertheless, when the gastritis pattern is unknown before the antibiotic administration, the effect of H. pylori eradication on gastric acid secretion and the incidence of GERD is unpredictable. In the exceptional cases in which H. pylori eradication could have negative effects on GERD, its clinical relevance will be limited, and reflux symptoms or endoscopic esophagitis will favourably respond to the standard PPI antisecretory treatment. Therefore, again, when H. pylori eradication is indicated in a particular patient, the concomitant diagnosis of GERD should not change our attitude. Finally, is has recently been recommended to eradicate H. pylori infection in those patients with GERD needing long-term treatment with PPI, as some studies have reported that these drugs induce, in presence of the organism, an atrophic gastritis, with the consequent risk of gastric cancer. However, most of these studies have important methodological defects, and several authors have reported contrary results. In any case, the appearance in the gastric mucosa of clinically relevant lesions, such as intestinal metaplasia, dysplasia or adenocarcinoma, in patients treated with PPI for several years, has not yet been demonstrated, although this could simply be a problem of time. This question seems to be too controversial to be answered with the available data, and we should wait until new studies clarify this topic. In the meantime, as it occurs with any controversial indication, the decision of the doctor facing a patient infected by H. pylori and needing maintenance therapy with PPIs should be assessed on a case by case basis.

[Antireflux therapy--more than acid reduction?]

Because gastroesophageal reflux disease (GERD) is a motility disorder, acid reduction with proton pump inhibitors (PPI) remains a symptomatic therapy with a recurrence rate of over 90% after discontinuation of acid suppression. This "therapeutic dilemma" becomes obvious in patients not responding sufficiently to the conventional medication (therapy resistance, necessity of high PPI doses, volume reflux). In this manuscript we analyze additional factors that may play a role in the pathogenesis and interpretation of GERD. These additional factors include gastroesophageal motility and esophageal barrier functions as well as duodenogastroesophageal reflux and Helicobacter pylori infection. In addition, basic problems in interpretation of therapeutic success such as placebo effect, spontaneous remission of GERD, the role of sensory function and subjective interpretation of symptoms and the overlap between physiological and pathological reflux as well as functional disorders will be discussed.

Symptom response and healing of erosive esophagitis with proton-pump inhibitors in patients with Helicobacter pylori infection

OBJECTIVES

The aim of this article is to determine the severity of esophagitis and the response to treatment with proton-pump inhibitors in patients with and without evidence of Helicobacter pylori infection.

METHODS

This retrospective analysis evaluated data collected in a randomized, double-blind clinical trial that assessed the efficacy and safety of once-daily esomeprazole 40 mg (n = 2,624) versus lansoprazole 30 mg (n = 2,617) for up to 8 wk in the treatment of reflux-associated erosive esophagitis. At baseline, erosive esophagitis was graded using the Los Angeles (LA) classification; serologic testing for H. pylori was performed using a FlexSure HP serum test.

RESULTS

There were 14.7% of patients who were seropositive for H. pylori. The percentages of seropositive and seronegative patients with each grade of esophagitis were: LA grade A, 38%, 36%; LA grade B, 41%, 39%; LA grade C, 16%, 19%; and LA grade D, 5%, 6%, respectively. Severe heartburn was present at baseline in 42% of H. pylori-positive and 42% of H. pylori-negative patients. Life-table healing rates with esomeprazole were not influenced by H. pylori status (seropositive 92.6% (95% confidence interval: 89.8-95.4); seronegative 92.6% (95% confidence interval: 91.4-93.7)). The rates with esomeprazole were significantly higher than those with lansoprazole (seropositive 90.5% (95% confidence interval: 87.5-93.5); seronegative 88.5% (95% confidence interval: 87.1-89.8)) after adjusting for baseline H. pylori status (p = 0.001).

CONCLUSIONS

The severity of erosive esophagitis at baseline was similar regardless of H. pylori seropositivity. Healing rates were not influenced by H. pylori status.

Influence of Helicobacter pylori eradication on gastroesophageal reflux symptoms and epigastric pain in children and adolescents

OBJECTIVE

Conflicting reports have noted a possible association linking eradication of Helicobacter pylori with aggravation of gastroesophageal reflux (GER) disease. We prospectively evaluated the effect of eradication of H pylori on GER symptoms and epigastric pain and the association among these 3 parameters in a pediatric cohort.

METHODS

Patients who were referred for gastroscopy were evaluated for frequency, severity, and nocturnal presence of symptoms related to GER as well as epigastric pain. Patients who were positive for H pylori received triple antibiotic therapy. The patients were followed for at least 6 months after therapy. Patients with successful eradication had symptoms compared with their pre-eradication state and were compared with a cohort of patients without H pylori or those with persistent H pylori.

RESULTS

Of 119 children and adolescents who were recruited, 95 patients completed the study, with a mean follow-up of 11.2 months. The distribution of outcomes for each GER symptom (better, worse, unchanged) was similar before and after eradication and did not depend on prior H pylori status. Among patients with GER and epigastric pain, improvement in epigastric pain was significantly correlated with the improvement in GER symptoms but not with eradication of H pylori.

CONCLUSIONS

Eradication of H pylori is not associated with increased symptoms of GER in children and adolescents. Improvement in epigastric pain in children is significantly correlated with the improvement in GER symptoms but not with eradication of H pylori.

Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is generally a lifelong illness that affects many people, but its significance is often underestimated. Chronic abnormal gastric reflux results in erosive esophagitis in up to 60% of patients with GERD. Esophageal stricture, Barrett's esophagus, and esophageal adenocarcinoma are the most serious complications of GERD. Although heartburn and acid regurgitation are the most common complaints, extraesophageal symptoms such as noncardiac chest pain, laryngitis, coughing, and wheezing can be manifestations of GERD. Unfortunately, the severity of symptoms is not a reliable indicator of the severity of erosive esophagitis. Endoscopy is the preferred method to diagnose and grade erosive esophagitis, and various classification systems are used to grade disease severity. The Los Angeles Classification is a valid and widely accepted system to evaluate the severity of erosive esophagitis. The immediate goals of treatment are to provide effective symptomatic relief and to achieve healing in patients with esophageal damage. The treatment regimen often begins by prescribing a therapy to reduce gastric acid secretion. A proton pump inhibitor is the preferred agent for many patients. Because GERD is a chronic, relapsing disease, long-term maintenance therapy is usually necessary to relieve symptoms, prevent complications, and improve the quality of life in patients with GERD.

Oesophageal disorders: future developments

Elicitation of the characteristic symptom patterns remains the primary approach to the diagnosis of gastro-oesophageal reflux disease, and this may be enhanced by developments in the use of high-resolution endoscopy and oesophageal biopsy. For future therapy, proton pump inhibitors and anti-reflux surgery may compete with reversible acid pump blockers, reflux inhibitor drugs and diverse luminally delivered physical anti-reflux therapies. Short-segment Barrett's oesophagus is known to be highly prevalent, but its impact on the risk of adenocarcinoma remains poorly defined. Biomarkers for Barrett's oesophagus have been proposed to aid in the stratification of cancer risk, and cytology may assume more importance in the future. Endoscopic surveillance for Barrett's oesophagus is widely practised, but more data are needed to demonstrate cost-effectiveness and a positive impact on mortality. Animal and limited human studies suggest that chemoprevention may become an important strategy in reducing the risk of adenocarcinoma. The ablation of Barrett's epithelium results in a reversal of Barrett's epithelium, albeit with an uncertain long-term outcome.

Gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) affects many patients and has a negative effect on quality of life. Along with the increasing prevalence of GERD is an increase in GERD-related complications, including Barrett esophagus and esophageal adenocarcinoma. The past year has yielded new insights into the pathophysiology of GERD that can help us to better understand the relationship between reflux episodes and symptoms of mucosal damage and to provide a tailored treatment targeting individual pathophysiologic defects. The issues addressed in this report include gastric secretory and motor dysfunction; failure of the antireflux barrier caused by hiatal hernia and transient lower esophageal sphincter relaxations; characterization of the refluxate, particularly of nonacid reflux; prevalence and prognostic value of esophageal dysmotility in GERD; presence and eradication of Helicobacter pylori; Barrett esophagus and extraesophageal manifestations of GERD; and, finally, advances in medical, endoscopic, and surgical treatments of GERD.

Minor effects of Helicobacter pylori on gastric secretion and dose of lansoprazole during long-term treatment in ZE and non-ZE acid hypersecretors

BACKGROUND

Helicobacter pylori infection may increase or decrease acid secretion and may augment proton pump inhibitor efficacy. Pepsin effects have not been reported. In Zollinger-Ellison syndrome (ZE) specifically, H. pylori has been reported to decrease acid.

AIM

To examine H. pylori effects on secretion and dose of medication in hypersecretors (basal acid output > 15 mmol/h) undergoing long-term treatment with individually optimized lansoprazole doses.

METHODS

Sixty-five patients (47 ZE and 18 non-ZE), treated for > 3 months to 10 years, were tested every 6 months with endoscopy, gastric analysis and serum gastrin.

RESULTS

Forty-three per cent were H. pylori-positive. Acid, pepsin and gastrin were not different between H. pylori-positive and H. pylori-negative patients before or during long-term lansoprazole treatment. Initially, H. pylori-positive patients required less lansoprazole than H. pylori-negative patients (68 +/- 6 vs. 96 +/- 8 mg/day), but after 3 years the doses converged (83 vs. 86 mg/day). The disappearance of H. pylori in 15 patients caused no significant changes in acid, pepsin, gastrin or lansoprazole dose in the following 4 years.

CONCLUSIONS

H. pylori had no significant initial or long-term physiological or potential clinical effects on acid or pepsin secretion or gastrin in these acid hypersecretors.

Helicobacter pylori: diseases, tests and treatment

Gastroduodenal disease associated with Helicobacter pylori infection are reviewed as well as the diagnostic approach. Generally, there are by and large two ways in which a diagnosis of infection by Helicobacter pylori can be made: by using either an invasive or non-invasive procedure. The invasive procedures involve endoscopy and biopsy Biopsy is essential since the mucosa may often appear macroscopically normal but, nevertheless, be inflamed. Once a biopsy is obtained histological examination, culture, polymerase chain reaction, detection of the presence of urease activity can be detected. The non-invasive tests that can be used to diagnose the infection are: serology, detection of labelled metabolic products of urea hydrolysis either in the breath (13CO2, 14CO2), the urine or the blood, detection of Helicobacter pylori antigen in stool specimen. At present, no single test is sufficiently reliable to definitely detect colonisation by Helicobacter pylori, and a combination of two is recommended, if feasible. Choice of the test to be used is not straightforward and relies on a series of situations, i. e., clinical setting and local expertise and availability, that the clinician must consider to obtain the best diagnostic yeld. The challenge of Helicobacter pylori eradication is not very easy to obtain. The possible scenario and the use of a new proton pump inhibitor (esomeprazole) are reviewed and discussed.